Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
A: Without knowing all the specifics, I would say the UTI could not be taken as the principal diagnosis. For the UTI to be the principal diagnosis, we would need to query for two pieces of information.
The first issue would be whether or not the UTI was present on admission. From this description, it does not was appear to have been present on admission; yet the symptoms appear before discharge.
The second concern would be to determine whether the UTI was somehow linked to the patient’s presenting symptoms. A UTI and SOB is a difficult connection to make.
If we eliminate the UTI as a choice, even if the majority of treatment was directed toward the UTI, we have little to work with. I would query for the probable or likely cause of the SOB. If the provider answers with a definitive diagnosis then this would be your principal diagnosis. If not, the symptom of SOB would be your principal diagnosis.
The bigger concern with this patient might be that the wrong status was assigned. This patient most likely should have remained outpatient and placed in observation status until a more definitive diagnosis could be found warranting an inpatient admission.
Editor’s note: Laurie Prescott, MSN, RN, CCDS, a CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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